ACLS

ACLS

1. signs

   • cardiac arrest pt  a)is not responding b)not breathing or is gasping c)no pulse With no pulse: high quality  CPR and defibrillation are the number one interventions- no drug can save the pt There are NO PULSE algorithms see steps for first line interventions
   • start trt: a)CPR  b)O2 c)monitor and defibrillator is attached  d) start CPR and assess rhythm every 2 min e)Do you continue CPR? If it's non shockable rhythm then continue CPR  how do you know?  asystole/pulseless electrical activity -PEA see p3 f) Do you shock pt? If there is a shockable rhythm(ventricular fibrillation / ventricular tachycardia)
   • Pulseless electrical activity (PEA) is a clinical condition characterized by unresponsiveness and lack of palpable pulse in the presence of organized cardiac electrical activity. Pulseless electrical activity has previously been referred to as electromechanical dissociation (EMD). (See Etiology.)While a lack of ventricular electrical activity always implies a lack of ventricular mechanical activity (asystole), the reverse is not always true. In other words, electrical activity is a necessary, but not sufficient, condition for mechanical activity. In a situation of cardiac arrest, the presence of organized ventricular electrical activity is not necessarily accompanied by meaningful ventricular mechanical activity. The qualifier “meaningful” is used to describe a degree of ventricular mechanical activity that is sufficient to generate a palpable pulse.PEA does not mean mechanical quiescence. Patients may have weak ventricular contractions and recordable aortic pressure (pseudo-PEA). True PEA is a condition in which cardiac contractions are absent in the presence of coordinated electrical activity. PEA encompasses a number of organized cardiac rhythms, including supraventricular rhythms (sinus versus nonsinus) and ventricular rhythms (accelerated idioventricular or escape). The absence of peripheral pulses should not be equated with PEA, as it may be due to severe peripheral vascular disease. 
   • risk factors for ACLS
     • 1.heart conditions like CAD, Arrhythmias, cardiomyopathy 2. smoker 3.HPT, hyperlipidemia, obese, DM, 4.sedentary 5. Older pt 6.male

2. Medications

   • THESE MEDS ARE FOR WHEN A PT HAS A PULSE NOT PULSELESS ACLS LIKE PULSELESS VT/VF OR ASYSTOLE/PEA
   • 1. SYMPTOMATIC BRADYCARDIA  ONLY TREAT IF UNSTABLE use   Atropine alternatives are percutaneous pacing or dopamine or epinephrine - see under Atropine
   • 2. SYMPTOMATIC TACHY must decide is it narrow , irregular or wide complex before treating a)narrow think SVT  and use ADENOSINE (first try vagal manouver methods first) b) irregular tachy - think AFib(rate control +/- cardioversion- so may use cardioconversion  with electricity if unstable here - lost BP, HR>150...) c)Wide tachy: think VTach Pt is there talking to you and they have V Tach need Amiodarone and Lidocaine is 2nd line
   • Epinephrine
     • 1.primary drug in ACLS 2.first line for VT,VF,PEA,asystole, 2.2nd line for bradycardia( decr HR)  
     • how does Epinephrine work? Physiological effects: a)potent vasoconstrictor which results in perfusion to the brain/heart b)Epinephrine also increases CO by increasing HR and contractility
     • Dose of Epinephrine? a) for VT , VF, PEA, asystole  1mg Epinephrine every 3 minutes to 5 minutes b) for Bradycardia: 2-10 mcg Epinephrine/min iv infusion
   • Amiodarone
     • 1 Indicated for VF or VT if epinephrine and defib failed 2 indicated for tachy if cannot use adenosine 3.Cannot use for polymorphic VT as amiodarone can widen the QT interval
     • How does Amiodarone work? Physiologic effects a)Class III anti arrhythmic b)blocks K channels  in myocardium to slow conduction and increase refractoriness
     • Dose of Amiodarone: a) VF or VT  300mg iv/io push followed by 150mg if no cardioconversion b)Tachyarrhythmia: 150mg over 10 minutes  repeat if recurrence: 1 mg/min for 6 hours then 0.5 mg /min c)max amiodarone 2.2gm in 24 hours d) need inline filter
     • Why It Is Done Cardioversion is used:2 As a nonemergency procedure to stop atrial fibrillation that has not stopped on its own. For people who have just started having episodes of atrial fibrillation, treatment typically includes cardioversion.As an emergency procedure if atrial fibrillation is causing your heart to pump dangerously fast or causing your blood pressure to drop dramatically.
     • hat To Expect After Treatment After cardioversion, you will be monitored to make sure that you have a stable heart rhythm. You will take an anticoagulant, such as warfarin, for at least a few weeks after your cardioversion. This medicine lowers your risk of a stroke. Additional medicines to help prevent the return of heart rhythm problems (antiarrhythmics) also may be given before and after the procedure. Your risk of having atrial fibrillation again is greater if antiarrhythmics are not used after cardioversion.
     • What To Think AboutCardioversion can also be done with medicines. These medicines are called rhythm control medicines, or antiarrhythmics. These medicines can also help keep your heart in a normal rhythm after it has been reset. You may get pills, or the medicine may be put into your arm through a tube called an IV. If an IV is used, it will be done in the hospital. You may start pills in the hospital and continue taking them at home, or you may start the pills at home.C 
     • Treatment Overview Electrical cardioversion is a procedure in which an electric current is used to reset the heart's rhythm back to its regular pattern (normal sinus rhythm). The low-voltage electric current enters the body through patches applied to the chest wall. Before cardioversion for atrial fibrillation, you will be given medicine to control pain and cause relaxation. For nonemergency cardioversion, the timing of when you have it depends on how long you have had atrial fibrillation and your risk of having a stroke as cardioconversion can cause a stroke
   • Adenosine
     • indicated for narrow-complex , stable  supraventricular tachy SVT and also indicated for stable wide-complex tachy
     • How does Adenosine work? a)Slows heart rate bc it slows conduction thro AV node. Adenosine is an AV nodal blocking agent...so can get an asystole so luckily it only has a t1/2 = 6-10 seconds and effect goes away b) restores sinus rhythm in SVT c) SVT : 6mg iv push  over 1 to 3 seconds followed by 20ml NS flushes d) may repeat with 12mg Adenosine dose in 1 to 2 minutes if still in SVT So  adenosine doses are 6,12 and 12
     • adenosine: t1/2 = 6-10 seconds so don't worry  if the pt goes into asystole (pt falls) after the dose because in 6-10 sec it is removed from body with short t1/2 and normal sinus rhythm should return. So some see a vasovagal response after adenosine dose- eg nonstop sneezing then bradycardia/syncope and pt falls. quick recovery
     • Because of very short t1/2 need to elevate extremeties and also need large fluid bolus afterwards If pt has Angina - caution as Adenosine can cause Angina in 30-40% of pts so of concern in CAD pt It can cause bronchoconstriction so avoid in asthmatics Theophylline, Caffeine, theobromine antagonise Adenosine so need higher dose of adenosine Carbamazepine , dipyramidole increase adenosine dose so need to reduce the doses 
   • Atropine
     • 1.DOC for bradycardia (HR<50 bpm) in ACLS THIS IS NOT PULSELESS LIKE PULSELESS VT/VF OR PEA/ASYSTOLE only use if they have UNSTABLE SYMPTOMATIC bradycardia don't treat if not symptomatic. give 1/2 mg Atropine max 3mg
     • How does Atropine work?  Physiologic effects: a) blocks effects of vagus nerve on the heart to increase HR t1/2 = 6-10 seconds so don't worry  if the pt goes into asystole after the dose because in 6-10 sec it is removed from body with short t1/2 and normal sinus rhythm should return  
     • Dose of Atropine: 1. For Bradycardia 0.5mg every 3 to 5 minutes  Max dose : 3 mg 2. Caution in MI as it can worsen  ischemia because heart now needs more O2
     • alternatives:  1)transcutaneous pacing OR USE VASO ACTIVE AGENTS:2)dopamine 2 - 10 mcg/kg/min3)epinephrine 2-10 mcg/min
   • Dopamine
     • indicated for Bradycardia as 2nd line  if atropine fails
     • How does Dopamine work? a)vasoconstrictor like epinephrine b) increases HR  and contractility
     • dose of dopamine: 2-10mcg/kg/min as iv infusion

3. First line Interventions

   • 1.use CAB now 2.Pulseless so need advanced cardio support 3.First if have pulseless Vtach and Vfib you need to defibrillate 4.CPR and Defib in this pulseless ACLS setting are the only options (no drugs help) 5. 2 algorithms with no CO  going on: it is either a)pulseless Vtach & Vfib- defibrillate this one and initiate CPR b) PEA asystole for these 2 initiate defibrillation ASAP then and start high quality CPR asap what is this CPR? a) begin CAB it is still 30-2 30 compressions - 2 breaths if it is a layman: only can do compressions b) rate and depth changes: 2"  (no more than 2.4" 100-120 compressions per min they added the upper limits c) allow chest to recoil- no leaning on chest - heart must refill to eject blood to body when you compress d) if you stop to check pulse it must be <10 sec to avoid any interruptions so now hace a chest compression fraction of 60 % (measure of length of compressing) want interruptions to be minimized
   • guidelines changed in 2015 1.its CAB now- not ABC... 2.so compressions and airways first now. 3.The depth of compressions is now 3 inches - not 4 inches any more (to not break ribs) 4. need to deliver 100-120 compressions per minute 5.Lay person can only give
   • 2015 BLS/ACLS guidelines
   • drug specific changes
     • a)Vasopressin removed from both algorithms in 2015 update b) Epinephrine is DOC in non shockable rhythmsin asystole and PEA start epinephrine asap in 1st 1-3 min (epi moved up- start asap - no longer wait until first CPR cycle  is done)i)administer within 1-3 minii) steroids reasonable to be given with vasopressiniii)bystander naloxone im or intranasal if it is an opiate OD(Evzio= auto-injector 0.4mg device for thigh) naloxone is new to guidelines
     • so only drugs are EPI and Amiodarone EPI after 2nd SHOCK for Pulseless VT and VF but  in Asystole and PEA :  give EPI after 1st CPR  AMIODARONE is the only antiarrhythmic approved and is given after the 3rd SHOCK in VF or Pulseless VT (although it was not proven to cause survival thus is far down in algorithm)
     • ACLS Pulseless VT or VF algorithm
       • 1)SHOCK 1: start with defibrillator  2)then start CPR high quality -2 min and get iv/io line reassess rhythm  3) SHOCK 2 (defibrillator) if needed 4)CPR -2 min 5) EPI - after 2nd shock can start drugs use epinephrine 1mg every 3-5 min consider advanced airway 6)Reassess rythm 7)SHOCK 3: defibrillator 8) CPR 2 min 9) AMIODARONE 300mg iv/io x1 and  may repeat at 150mg bolus dosex1  10) reversible causes of this even must be removed
       • give drugs after 2nd shock give EPI and give amio  after 3rd shock
       • ACLS Asystole/PEA Algorithm
         • see p 16 of Cardio 1 slides 1) CPR 2 min iv/io access established now 2) Epinephrine 1mg iv/io every 3-5 min and consider advanced airway 3)reassess rhythm 4)CPR 2 min treat reversible causes 5) Reassess rhythm and 6)SHOCK if needed 7)then repeat CPR and EPI  as for Pulseless VT/VF 8)if still no pulse : repeat CPR 2min EPI then SHOCK then CPR 2 min then reassess rhytm then SHOCK 
         • Asystole is a flat line or PEA this is again a pulseless situation and it should not be shocked  Give EPI early on remove causes of even 

4. Therapeutic Hypothermia

   • only intervention shown to improve neurological recovery- studies show 20-50% had good neurological function in 1 year EMT was using Cold fluids before hospitalization but it is not recommended now
   • 2015 guideline : a)all comatose - no verbal responses should get TTM b)target Temp 2-36 degrees celcius and kept there for 24 hrs

5. Torsades de pointes

   • Wide Polymorphic Ventricular tachy= Torsades de points (points are twisted) caused by drugs or electrolyte imbalances QTc>500 msec prolonged We must check for offending agent is Next see if they are stable or unstabe: if  unstable- can defibrillate them if stable: give iv Mag (correct K and Mg levels can prevent  Torsades) 
   • drugs causing torsades sotalol dofetilide haldol many others  Look for DI Look for QT prolonging drugs etc
   • Torsades: a) iv Mag can buy time -  make sure K(>4) and Mg (>2)levels are good b)withdraw offending med causing torsades c) can use